|Year : 2006 | Volume
| Issue : 1 | Page : 10-14
Place of menstruation in the reproductive lives of women of rural North India
Department of Community Medicine, PGIMER, Chandigarh - 160012, India
|Date of Web Publication||8-Aug-2009|
A J Singh
Department of Community Medicine, PGIMER, Chandigarh - 160012
| Abstract|| |
Objective : To ascertain the perceptions and experiences of women regarding menstruation. Methods : An integrated qualitative and quantitative study on reproductive health of Indian women was conducted in two primary health centre areas of rural north India. Present article reports on the perceptions of 1205 women regarding various aspects of menstruation. Results : Major source of information about menarche/menstruation was friends/relatives (72%). Mean age at menarche was ~ 15 years. Very few women (0.4%) used sanitary napkins. Majority of women had strong beliefs about effect of diet on menstruation. Most of them considered menstruation a dirty act and indulged in various taboo behaviours. Initial reaction was of fear/apprehension at menarche in majority of girls. Conclusion: Women in rural north India still hold tranditional beliefs regarding menstruation. Provision of a balanced and healthy family health education package to all girls is recommended.
Keywords: Reproductive Health, Menstruation.
|How to cite this article:|
Singh A J. Place of menstruation in the reproductive lives of women of rural North India. Indian J Community Med 2006;31:10-4
| Introduction|| |
The occurrence of menses indicates the non-pregnant status of a women. A missed period indicates the pregnancy. Every woman, therefore, awaits her next menstrual bleeding episode every month with a sense of expectation, anxiety or apprehension depending on the fact whether the pregnancy is wanted or unwanted. Moreover, because of the regimented life of monthly 'waiting period' a woman tends to plan her activities of daily life and in particular the outdoor activities and strenuous work accordingly , . Thus, menstruation becomes a central issue in her life. Her daily and monthly routine revolves around menstruation.
The pattern and extent of bleeding during menses and associated symptoms vary among different women e.g. the number of days of bleeding, the periodicity of (bleeding) cycles, the amount of bleeding and its association with pain or other features like nausea/vomiting. This makes such monthly episodes of bleeding individually unique for every woman.
However, the low social status of women in Indian society... the 'culture of shame and silence' associated with their reproductive health matters make public discussion on these topics a taboo. They are conditioned to hide everything related to their private lives.
Thus, till recently this area has been relatively unexplored by public health researchers. With this aspects in mind an ICMR sponsored multicentric project was conducted to ascertain the effect of utilization of mobile units on reproductive health needs of women  , . Present article reports on the perceptions of the women of rural north India regarding menstruation as revealed during initial baseline qualitative and quantitative data collection phase of the project.
| Material & Methods|| |
First, two primary health centre areas (PHC-1 and PHC-2) were chosen purposively from a district in north India - 30-40 km from the parent institution (PGIMER). PHC-1 was taken as the intervention area and the PHC-2 as a control area. The recruited staff (an anthropologist and four field investigators) were trained in survey techniques. Elementary knowledge on reproductive health was also imparted to the project staff. Using the probability proportionate to size (PPS) method 20 villages in PHC-1 (population 20692) out of total 37 villages (population 29930) were randomly selected. Similarly, 13 villages (population 27262) were selected randomly in PHC-2 area out of total 28 villages (population 37365). A baseline survey was conducted in both the areas. It was proposed to interview at least 500 women aged 15-49 years and their husbands from both the areas. A minimum of 10 interviews were held at each village. A uniform pre-structured interview schedule was used at all the centres. The schedule had details on - sociodemographic data, obstetric history, family planning and abortion details, gynecological morbidity profile and menstrual history.
Qualitative research on various aspects of reproductive health was also conducted by anthropologist and the PI. Initially, 16 key informant interviews were done by the anthropologist in some of the villages of the study areas. The first 2-3 interviews were held with traditional birth attendants and health workers. For the remaining interviews more key informants were selected on the basis of the information obtained from the previous key informants. These interviews provided the background material and the framework for conducting the focus group discussions (FGDs). Apart from 6 TBAs and 2 health workers, 2 local medical practitioners, 2 teachers, 2 opinion leaders and anganwadi workers were also used as key informants. Repeated interviews (3-5 visits) were held with them to get the relevant details. Information from various sources were pooled to get a complete picture. These exploratory key informant interviews also helped in developing appropriate vocabulary and in identifying relevant questions for FGDs and for the interview schedule.
Four FGDs were then organized by the female anthropologist (moderator) and the field workers (comoderators) to get insight into the terms used locally for various reproductive health problems and for menstruation before finalizing the interview schedule. These FGD participants were married women of 20-40 yrs age group. The FGDs helped in designing appropriate questions for the interview schedule and in exploring the prevailing range of beliefs and attitudes of the rural North Indian women regarding reproductive health including menstruation. Two of the FGDs were done in remote villages and the 2 in PHC headquarter villages.
Extensive notes were also taken during the session. Each FGD had 4-6 participants who were invited to a common and a neutral place in the village e.g. monthly meeting of local women organization (mahila mandal) which are organized regularly in rural areas of North India. Each FGD was analysed immediately after the session through a meeting of the moderator, comoderator and the investigators. Considerable flexibility was given in the qualitative phase of the study for data gathering and interviewing process. Emphasis was given on recording verbatim responses.
Based on the results of the key-informant interviews, and the FGDs an interview schedule was prepared which was modified after the pretesting. Then, after finalization of the interview schedules a house to house survey was done in the selected villages. All women aged 15-49 years, were contacted. Their consent for the interview was taken. Each woman was interviewed individually with emphasis on privacy.
| Results and Discussion|| |
Profile of respondents:
Overall, 1205 women were interviewed (591 from the experimental PHC and 614 from the control PHC). Of them, 10.8% were from a PHC village, 32,8% from a SC (subcentre) village and 56.3% from a remote village. In all, 1056 households were surveyed. Hindus were 79.5%, Sikhs 12.3%, Muslims 6.35% and rest were Christian/others. Lower/lower middle class families were 85%. Rest were upper middle or higher class. Nineteen percent of the respondents were unmarried.
Mean age at marriage was 18.2 ± 2.8 years. Eight percent (98) women did not have any child. Of them, 33 were classifed as infertile (primary infertility 3.4%; 33/976). Of them 14 (42%) had consulted a doctor. Mean number of live birth, still birth, and abortion per woman was 3.0, 0.2 and 1.5 respectively. Mean number of living male and female children was 1.7 each. Outcome of last pregnancy was a live birth in 96% cases, still birth in 1.4% and abortion in 2.7% cases. Sex of the child in the live birth was male in 66% cases and female in 34% cases. Mean age of the last child was 53.1 ± 36.1 months.
Mean age at menarche was ~ 15 years. It was significant to note that only 5 women (0.4%) used market-pads for menstruation and that girls did not use any underwear in routine before attaining menarche. Chatterjee et al  had also reported that use of market pad was low (2-8%) in an urban slum area of North India. Majority of their respondents (70-76%) did not even use any underwear in routine life.
The perceptions of women regarding menstruation as revealed in this study are similar to the conceptual framework of rural north Indian males pertaining to women's illnesses as reported by the investigators earlier  .
| A women is considered dirty during her menses|| |
Many restrictions are imposed on women during menstruation in Indian rural setting. Many daily household chores which are considered 'holy' or 'sacred' are proscribed  . Garg et al  also reported that the subject of menstruation revolves round notion of dirt, taboos and restrictions in various spheres of women's lives in India.
In our study also many women said, "During menstruation a woman is considered impure or contaminated/dirty. So, all kinds of restrictions are imposed on her".
One of them said, "We do not go to the place of worship or light the holy lamps during (during menses)... since it is a holy place. It will be desecrated if a woman goes there during menstruation. We do not offer food to Brahmins/Priests, do not observe religious fasts, do not organize recitation of holy/ religious stories (katha) at our homes, and do not light incensesticks".
Another woman said, "if at all we have to go to temple (during menses)... we first wash our hair... i.e. a purifying bath... then go".
One woman told that she did not cook anything in kitchen during menstruation. This is also linked to their belief regarding their being impure/dirty during menses. Similar findings were reported by Garg et al. 
Another one said, "we do not lift heavy weights during menses.... it leads to pain"... such comments indicate that women consider their bodies to be weakened during menses.
Another group of women said, "we do not have sex during menses... because if we do so... it leads to swelling inside... and secondly, it feels all filthy to have sex during menses".
Thus, the routine life of women, in general, is profoundly affected by the monthly phenomenon of bleeding during menstruation.
| The cloth-piece used as menstural pad-its disposal and reuse|| |
The concept of evil-eyes and magic is strong in India. The piece of cloth/rag/pad used for menstrual bleeding is considered by rural Indian women as one of the most vulnerable object and a potent agent which might be used for casting evil eyes/magic on some one. There is a belief prevalent in the study area that women often throw their 'used' rag/pad at road crossing to cast evil eyes/magic on others. Anybody who steps over this thrown rag/pad is said to become the victim of evil eye/magic. This piece of cloth is considered a part and parcel of the secret world of women's lives...so, all attempts are made to hide/conceal the rag/pad... Thus, its disposal assumes a special significance in the daily lives of Indian women.
When our field-investigators asked the women if they reused the cloth-piece used earlier for menstruation... many women laughed at them... as if they had asked a very funny/ridiculous question. Some of them reacted as if the investigators were insulting the respondents. They said, "it (the soiled rag) is a disease... why to keep it inside the house..." & "Oh! who will wash and reuse such a dirty thing... we throw it away on the garbage heap... or bury it under the earth..." (as told by a Muslim woman). When they were asked... 'why do you bury it", they told, "it is shameful if anybody sees our dirty (stained by menstrual blood) rags... suppose, some dog takes it away... all private and secret/hidden things of women will come out in the open... It will be very disgusting. If we casually throw it away... all filth will spread and scatter around in the whole village... so we bury it... so that nobody comes to know about it".
One of the women said, "it is dirty blood... why should any animal... child or a person touch it".
Reuse of the cloth-pad was told by 4% respondents only in our study. Their responses revealed that the cloth-pad used for menstruation was considered a dirty thing and hence the dislike for its reuse. Garg et al  also report reuse of cloth by only 6.5% of their respondents. However, their premise that reuse was more common in villages could not be corroborated in our study area where the women opined that such dirty practices existed in cities only.
One of the women even taunted the lady-interviewers of our team... "We in villages, do not display/exhibit the filth (as the city dwellers do). We do not wash it (the dirty rags) for using it again... there is no shortage here...plenty of rags are available... This dirty act (of reusing the rags) is done in urban areas only... because in cities there is no place to dispose off the dirty rags... and the women have to wash the same (dirty) cloth again and again".
Some women were of the view that the same cloth should not be used again, since.... "it is a kind of disease... all types of jaraseem (germs) are discharged from inside... if we reuse the same cloth... we will get many illnesses". This reflected that women in rural India also have their own 'scientific' justification of their reproductive behaviour.
Another woman told about her menstrual history... "I considered it a dirty thing... But if it does not happen (menses)... even then it is not good... it will spread illness inside us... It used to come every month... However, after the operation (tubectomy) it comes every 20-22 days".
| Changing times and early menarche|| |
People in villages wer aware that these days the girls are having menarche at an early age as compared to previous times. In fact, they had their own opinions regarding the reasons for such a change. One of our respondents told, "Nowadays girls start menstruating at a very early age... even at 12 years age... what can we say... the times are bad... it is the effect of modernization... it is Kalyug... nowadays, the girls know everything soon after they are born... everyone has TV nowadays... on which everthing is explained... all this (the early menarche) ...is due to TV".
| Dietary theory of early menarche|| |
There is strong diet fixation among general population in India about various aspects of health and disease. In our study also, change in diet was told as a cause for early menarche... as one of our respondent told - "... because of rising cost of living, even villagers (who have milch animals) can not afford to consume the milk... and they are forced to sell it... everyone (including the girls) consumes more of tea... and even in that... raw sugar is used (instead of jaggery)... which cause heat inside... leading to early menarche". Another woman said, "use of English fertilizers/pesticides in fields/crops leads to early menarche".
Continuing on the theory of changing times and change in dietary pattern, one woman said, "Earlier the girls never went to school... now they study... it strains their minds... so, they require nutritious diet... we give them eggs, meat etc... which leads to heat inside... and girls start menstruating at an early age". Another woman told, "consumption of pickles and other sour things like tamarind leads to early menarche".
Many dietary restrictions were also told during menstruation... as one women said, "we don't take rice... curd, curd-milk (lassi)... i.e. the 'cold' things... during menses, since consumption of such things leads to pain during menses. Any items producing 'wind' or 'vata' are also not used... like rice, radish, potato, sugarcane and onion". George  and Joshi et al  also reported that women avoided hot-spicy food during menses as they thought that these things increased the menstrual flow.
Women in our study area also practiced their dietary theory in the field of contraception... as one of them told... "we (deliberately) take some hot things (dry ginger powder, spices, chillies, jaggery) every month... so that the period comes on early and on time (and this coming of period implies that the lady is not pregnant). Thus, a belief existed among them that 'hot' things hasten/facilitate the menstruation... and thus prevent conception.
| The first reaction to menstrual bleeding at menarche|| |
Majority of our respondents said that they had no prior knowledge about menstruation when they experienced their first menstrual bleeding. Fear/panic was the dominant reaction among many girls when they first had their menses. This is true for majority of girls in rural and even in urban India  . Garg et al  also reported that at menarche only 12% of their respondents had any prior knowledge about menstruation.
Responses of one of the women revealed the problems girls face in rural Indian set up when they have their first menses... as she told...
"I was in the school when it first happened. I noticed that my salwar was stained/spoiled. I thought it (the bleeding) was due to the boils... But one of my friends told me that I should go back to my home (it was a co-educational school). My teacher (female) also asked me to go home...saying that girls have such problems every month. My friend escorted me to my home.
My father asked, 'why have you come back to home (early) at this hour'. I told him (a lie) that I had forgotten a note-book at home. My mother was not at home at that time. It was my friend who told me how to use a menstrual pad. Before that I had never used an underwear. So, I did not have any underwear at that time. I had to borrow an underwear from my sister. She asked if I had started menstruating. I said 'yes'. My mother came to know of this quite late'.
Thus, menarche... the heralding phenomenon for the initiation of the girl in reproductive life i.e. the onset of menses is also ridden with a lot of apprehension, fear, shame and disgust on the part of the young girls.
One of the respondents in our study recounted her experience of menarche... "I told my cousin about the bleeding and told her that I did not know what was happening to me. Probably it is some ghost or spirit casting its evil shadow on me. Then my cousin told me about it (the menses)".
Another women told about her reaction to the first episode of menstrual bleeding -
"My abdomen was aching and I was afraid... I panicked when I saw blood stains on my salwar. I wondered if I had sustained some injury. I could not comprehend the cause of this bleeding. Then I told my sister-in-law (about the bleeding)".
| Source of information on menstruation|| |
In only one case mother was the first person to explain her daughter about menses "My salwar had a (blood) stain on it... my mother came to know of this. She asked if I knew about it. I replied in negative. Then she told me about it. She said... you are grown up now... it (the bleeding) is a sign of maturity in girls...".
The communication between the mothers and the daughters regarding menstruation or other such matters appears to be minimal. In our study, friends (72%) or other female relatives (17%) were the first people to tell the girls about the menstruation i.e. how to use pads/cloth piece. Similar findings were reported by others  , , . The code of silence and secrecy pertaining to these issues implies that the girls hide/conceal these events from their male relatives i.e. brothers/fathers and even their mothers initially... who get to know of it sooner or later.
The women told that they felt shy to discuss such things with their mothers. Even the mothers did not talk about these things with their daughters. In some cases the women relatives asked the girls not to discuss these things with their mothers. This distance from mother appeared to be due to the respect given by the girls to their mothers. They did not seem to have intimate friendly relations with their mothers. As one woman said, "such matters are not (supposed) to be discussed by the daughters with their mothers".
However, women have an elaborate system of informal consultation with their peer groups, female relatives (cousins or aunts) regarding their reproductive health matters. Joshi et al  and Garg et al  also reported that sisters, friends, sister-inlaw were the people consulted more frequently by their respondents for problems related to menstruation. None of them consulted their mothers.
At menarche, these people initiate the bewildered girl.... (who experiences the sudden and shocking occurrence of her first episode of menstrual bleeding and is often mentally not ready or prepared for the event...) into an elaborate set of prescriptions and proscriptions, taboos and rituals ralated to menstruation. Gradually, after attaining maturity the women develop various beliefs about different aspects of menstruation... what causes early menses... what leads to excessive menses... what to eat... what not to eat... what to do and what not to do during the days of menstruation.
One of the women told about her views ragarding educating her daughter about menstrual hygiene. "For my daughter (aged 7 years)... this is not the appropriate time (to tell about menses)... it is in the hands of Nature... whenever it will happen... we will have to tell her".
| Health implications of menses|| |
'At the first time there was not much bleeding... there was, of course, severe pain in abdomen 2-3 times... but I did not tell anyone in my family... the pain in abdomen remained for 5-7 cycles... it got O.K. by itself... and now it does not pain during menses anymore... my periods are regular... and always on time... and never get delayed.'
"I did not like it even at the first menses... even now I consider it filthy... my heart feels unsettled... and I have a nauseating feeling... The bleeding persists for 3 days... on the first day... it is heavy... and for next two days it is average flow... Before marriage it used to be for 5-6 days. Now, I often say that it is better that this trouble gets over once for all. When I use rag/ cloth (for menses) I have gas formation in my stomach... and I get the heat".
| Marriage and menstruation|| |
Intimate relation of the day of marriage and the date of menstruation was revealed by the narrative of one of our respondent - When I got married I has started menstruating the day before. It was my second day of bleeding. But my husband did not spare me... we had sex on the first night itself... My sisters, sisters-in-law and my husband's sister everybody had asked me not to have sex during menses... i.e. on the first night... but, do men ever spare women?... so we had it (the sex)... he said (why) should I spare you on the first day (of the marriage) itself?" However, thereafter he never troubled me during menstruation days.'
| Conclusion|| |
Thus, our study results (both from qualitative research data and quantitative survey revealed that prior to menarche, knowledge about menstruation was deficient among the respondents. There was a strong belief among the women respondents of our study area about the effect of diet on menstruation age at menarche, date of bleeding and amount of bleeding. Ten percent of the women reported observance of various taboo-behaviours related to menstruation. Regular monthly bleeding episodes during menstruation was considered as purifying process which cleansed the women's body of the dirty blood.
Initial reaction of majority of girls to the first episode of bleeding was of a sense of fear/apprehension. Such fear needs to be tactfully dispelled from the mind of adolescent girls so that they develop a balanced and healthy outlook towards their prospective reproductive lives. Thus, there is a need to provide healthy family life education to the women of our study area... particularly the young girls. Appropriate educational package may be developed for school going girls. Non-school going girls may be educated through meetings held at Mahila Mandals/Anganwadi centres. Mass media may also be utilized to encourage menstrual hygiene among adolescents. These aspects should be kept in mind while planning any intervention, educational or otherwise, regarding reproductive health of women.
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